DRUGS: Needle exchange programs: the facts

by Mark Souder

News Weekly, June 5, 2004

Drug harm-reduction policies, such as injecting rooms and syringe distribution programmes, have failed to stop the spread of hepatitis and HIV. Recent US and Canadian findings provide important arguments against Australia's harm-minimisation policies.

As is well known, "harm reduction" is an ideological position that assumes individuals cannot or will not make healthy decisions. Advocates of this position hold that dangerous behaviours, such as drug abuse, should be accepted by society, and that those who choose such lifestyles should be enabled to continue these behaviours in a less harmful manner.

Often, however, these lifestyles are the result of addiction, mental illness or other conditions that should be treated rather than accepted as normative, healthy behaviours.

Harm-reduction programs that sustain continued drug abuse, such as injection rooms and needle distributions, are likely to weaken drug-abusers' defences against infection, sustain drug-abusers' long term risk for disease, and minimise the benefits of the available treatments for HIV disease.

These dangers seem to have received insufficient attention by some US federal health agencies. Yet, peer-reviewed scientific and anecdotal evidence appears to support this assertion.

Needle exchange is the most visible harm-reduction program for injection drug-users. The first needle exchange programs in the United States were established in Tacoma, Portland, San Francisco, and New York City in the late 1980s in an effort to prevent HIV infection among injecting drug-users. By 1997, there were 113 such programs in more than 30 states.

Vancouver, Canada, administers the largest needle exchange program in North America, distributing nearly three million needles every year. The city has a publicly sanctioned site specifically designated for addicts to inject under medical supervision absent of law enforcement.

Results "horrific"

The results of this approach have been horrific. When the Vancouver needle exchange program was established in the late 1980s, the estimated HIV prevalence in Vancouver was 1 to 2 per cent among the city's population of 6,000 to 10,000 injecting drug-users. While the expectation was for needle exchange to decrease HIV rates, the opposite has occurred.

Both HIV and Hepatitis C have reached "saturation" among the injection drug-using population, meaning few if any of those who are not already infected are left to become newly infected, according to the Vancouver Drug Use Epidemiology report published in July 2003.

The HIV prevalence among the Vancouver study sample is 35 per cent with "one of the highest incidence rates reported worldwide". The Vancouver study also records an astounding 82 per cent prevalence of hepatitis.

Research has directly linked the needle exchange program to this trend. A 1997 study found that "frequent needle exchange program attendance" was actually one of the "independent predictors of HIV status" among injecting drug-users.

Of those injecting drug-users observed who became HIV-infected during the course of the study, about 80 per cent said they had no difficulty accessing syringes. With only one lone exception, the needle exchange program was the main source of syringes for all of those who became infected. 76 per cent of HIV-positive injecting drug-users studied admitted to borrowing used needles, as did 67 per cent of HIV-negative injecting drug-users. Thirty-nine per cent of HIV-positive injecting drug-users lent used needles.

The failure of harm reduction to control infectious disease is not limited to Vancouver. A two-year case-control study in Montreal, involving nearly 1,600 participants, suggested that consistent needle exchange use continued to be associated with higher rates of HIV infection.

A study of needle exchange programs in Seattle found no protective effect of needle exchange on the transmission of Hepatitis B or C among participants. The highest incidence of infection with both viruses occurred among current users of the needle exchange.

Needle exchanges focus almost exclusively upon a single mode of transmission among injecting drug-users - sharing of contaminated needles - and largely ignore other important factors such as the behaviours that cause risk-taking, the impact of the substance on the individual and the substance being abused itself.

A 10-year study published in the Archives of Internal Medicine found that the biggest predictor of HIV infection for both male and female injecting drug-users is high-risk sexual behaviour.

Moreover, according to a study published in the European Journal of Public Health, drug abuse reduces the benefits of AIDS therapy.

This is an edited summary of a letter dated April 27, 2004, from Mark Souder, chairman of the US Congressional Subcommittee on Criminal Justice, Drug Policy and Human Resources to the US National Institute of Health.